Dissection

Images Dr Juan Chiang

An 85 year old man is brought in by ambulance after a syncopal event. He was hypotensive on scene, BP 78/50. He is  given fluid by the paramedics but remains hypotensive.  He has no chest pain and is not short of breath. On arrival to the Emergency Department he is alert, clammy, pale and profoundly hypotensive.  He has a history of a thoracic aortic aneurysm. A thoracic aortic dissection is suspected.

A point of care ECHO is performed on arrival. This is his subcostal view.

Coagulated blood in the pericardial space appears hyperechoic

In early systole (as the RA fills), The intra pericardial pressure is greater than the intra atrial pressure and there is RA free wall collapse (blue arrow)The longer the time the RA wall remains collapsed during the cardiac cycle the higher the intra pericardial pressure. RA wall collapse which is greater than 1/3 of the cardiac cycle is significant

In early diastole, as the RV is filling,  if the intra pericardial pressures exceed the RV pressures,  then the  RV free wall collapses (blue arrow). This can be seen here.

This man has cardiac tamponade as is severely haemodynamically compromised from his haemopericardium. He has echo signs which support this.

Unfortunately he did not survive.